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I can confirm that the Ombudsman has forwarded his report to us and requested that we consider further action. We are currently considering our next steps as part of the work we are taking forward to strengthen and focus our risk assessment, inspection and follow-up processes in light of the Francis Inquiry report

'We've seen a number of cases where people at the end of their life have not been cared for properly," says Public Services Ombudsman Peter Tyndall.

"I think there are instances where cultural change will be called for. In many cases there is excellent care being provided, but there are still isolated cases of this kind that need to be tackled."

The distress of the family in losing a loved one is a matter of great concern. I think for them this is something that will always remain with them and it does again stress the importance you have to look after people at the end of their lives well.

"I am confident that the changes can be made and will be made, but I think it requires sustained management attention to make sure that we don't slip away from the standards that need to be sustained."

It says the ward in which Mr was treated has now been replaced by a purpose-built dementia unit, and that the hospital now has "better mechanisms in place to assess and serve patients' nutritional needs".

We would like once again to offer our most sincere condolences to the family of this patient for their sad loss; and to apologise for the shortcomings in important aspects of care this patient received, which we acknowledge fell well below the high standards expected.

We would like to give assurances that there have been major changes since the time this patient was an inpatient at Cefn Coed Hospital, particularly around pressure ulcer prevention.

Pressure sores are not acceptable, and in almost all cases they are avoidable. Our clinicians have been determined to find ways to greatly reduce the risk of patients developing pressure ulcers, and in 2008 we began a major programme developing interventions to prevent pressure ulcers.

We successfully piloted this early work in 2009, in a small number of acute wards. They are now in use at all our hospitals, where nine wards have prevented patients developing any pressure ulcers for over three years; and a further seven wards have stopped pressure ulcers for over two years.

More needs to be done to care for elderly people in hospitals that are coming to the end of their lives, according to the Public Services Ombudsman for Wales.

It comes as a report is published today revealing 'a pattern of failures' in the care of a man with dementia who died four months after being admitted to Cefn Coed Hospital in Swansea.

Abertawe Bro Morgannwg University Health Board, which was criticised in the report, says it has overhauled some parts of its service since 2009 when the man died - and in the area of bed sore prevention it is now a world leader.